Member states have endorsed reforms to World Health Organization (WHO) management and priority-setting processes, though many global health experts suggest actual change has been too slow and many needed reforms, particularly ones related to financing, have yet to be addressed.
The need for WHO to become more transparent, focused on results, accountable and effective was agreed upon by delegates to the 65th annual meeting of the World Health Assembly from May 21–26 in Geneva, Switzerland. The governing body also laid out five priorities for future WHO activity: communicable diseases; noncommunicable diseases; health through the life-course; health systems; and preparedness, surveillance and response.
“All delegates emphasized that WHO should increase its focus on the social, economic and environmental determinants of health,” states a summary of discussions forwarded to CMAJ by WHO.
But the “real” issue in the reform process — how to make WHO’s future governance more inclusive and participatory by involving external stakeholders such as philanthropic bodies and industry — was not even addressed, according to Tikki Pang, a visiting professor at the Lee Kuan Yew School of Public Policy, National University of Singapore, and WHO’s former director of research policy and cooperation.
“This key issue was not even on the table purely and simply because the Member states are unwilling to cede/share their decision-making powers with others,” Pang writes in an email. “Without this fundamental change I believe that reform will be largely cosmetic and focused on process, an emphasis on ‘the trees and not the forest’.”
Another core reform issue that wasn’t discussed was how WHO finances its operations. The organization is suffering a financial crisis due to several factors, including the falling value of the Swiss franc. Last year, it slashed its annual budget of $US4.5 billion by nearly a quarter and announced plans to cut 300 jobs at its Geneva headquarters (www.cmaj.ca/lookup/doi/10.1503/cmaj.109-3933).
“The whole budget of the WHO is more or less equivalent to that of one teaching hospital in a rich country,” says Dr. Mohga Kamal-Yanni, senior health and HIV policy adviser for Oxfam GB (Great Britain), based in Oxford. “We are talking about a quite modest budget.”
About 80% of that budget comes from voluntary donations that are earmarked for particular causes, resulting in a misalignment between financing and the disease burdens of most member nations. This leaves little flexibility for WHO, having only the small sum accumulated from member state contributions to devote to priority areas. Couple that with WHO’s tendency to spread itself too thin and you have the classic resource-allocation conundrum: doing too much with too little.
“I don’t see that they have found a proactive way to limit the scope of what they do,” says Amanda Glassman, director of global health policy at the Center for Global Development, based in Washington, DC. “And there’s still the financing problem. It seems as if that has fallen off the agenda and I don’t know why that would be, because it’s one of the biggest issues.”
There have been calls for WHO to make better use of its limited resources by narrowing its focus for specified periods of time. Indeed, many of the health problems it once championed have since been adopted by other groups. By 2008, there were a host of nonprofit organizations, charities, global health initiatives, global and regional funds, bilateral donors, United Nations agencies and other health organizations operating in 54 countries with a collective annual budget of US$22 billion (www.cmaj.ca/lookup/doi/10.1503/cmaj.109-3701).
“The WHO is in budget crisis and struggling to maintain its relevance in a crowded landscape of better funded, more agile philanthropic foundations and disease-specific initiatives. Without a commitment to bold reform and greater efficiency, the future looks bleak for WHO,” Thomas Bollyky, senior fellow for global health, economics and development at the Council on Foreign Relations in New York City, New York, writes in an email. “It is a moment for bold changes, not incremental ones. Unfortunately, the latter is what we got [at the World Health Assembly].”
Launched in 1948, WHO has been considered among the most successful of United Nations’ agencies. It set best practices for fighting diseases, helped combat smallpox, led efforts to immunize newborns and explored the link between poverty and disease. Though the proliferation of other global players has diminished its stature, most health experts agree that it still has an important role to play.
“Firstly, and quite simply, despite all its shortcomings and current problems, it is an irreplaceable agency in that it is the only global organization which champions the health of underprivileged populations,” writes Pang.
This is why many global health observers, concerned about WHO’s viability, stress the importance of reform. And though implementation of reforms may be moving at a crawl, WHO Director-General Dr. Margaret Chan should be commended for initiating the process, according to Laurie Garrett, senior fellow for global health at the Council on Foreign Relations.
“It is clear from her speeches and the key proposals ushered through the World Health Assembly that DG Chan knows what needs to be done, and is trying to steer WHO in a sound direction,” Garrett writes in an email. “But there are deep structural issues to overcome: Nothing will transpire quickly. … She is steering her ship along rocky shoals.”